Routine inspection (multi-day)·August 29, 2023

Licensing Program Analyst (LPA) Tao conducted a subsequent unannounced annual inspection visit. LPA met with Administrator, Ana Stark Pleitez, who assisted with the visit. The facility is licensed to serve six (6) non-ambulatory residents who are ages 60 and above and approved for four (4) Hospice Waiver. Facility had dementia program on file. Currently, two (2) residents on hospice. Annual licensing fees are current. LPA discussed the purpose of today's visit with administrator. The annual inspection consisted of interviews of staff/residents, use of CARE inspection tool, tour of the facility, review of food supply, review of medications, and reviews of staff/residents records. The facility is a single story home located in a residential neighborhood, consisted of four (4) resident bedrooms, four (4) bathrooms, a kitchen, a dining room, a living room with TV and a garage, and indoor/outdoor activity areas. Resident bedroom #3 was a shared room with two residents residing there and had a divider at the middle of the room. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. Sufficient of linen supplies and personal hygiene supplies were observed. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. Side and front yards are well maintained and free of debris. There is shaded outdoor area with ample seating. No bodies of water observed. (-continued in LIC 809 C-) Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean. Plates, cups, glasses and utensils are sufficient for the current census. Hot water temperature is in a range of 128.5 to 129.5 degrees Fahrenheit which was NOT within Title 22 Regulation guidelines. Exit doors are equipped with auditory device alarms. Deficiencies were observed and cited per California Code of Regulations, Title 22. See LIC 809D for deficiencies. An exit interview was conducted. This report is discussed and provided to Administrator, Ana, whose signature on this form confirm receipt of these documents.